AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Tuberculosis (TB) has plagued humankind since antiquity. The effects of TB have been noted in skeletal remains from 4000 BC, and both Hippocrates and Galen described TB's clinical manifestations; however, prostatic TB was not described until the turn of the 20th century.

Despite optimistic predictions of the eradication of TB in developed nations, the disease continues to pose a major worldwide health problem. In 2004, the World Health Organization estimated that one third of the world's population either was infected or had been infected with TB and that 2 million deaths annually could be attributed to TB. Developing nations, which accounted for 95% of the 8 million new cases in 1990, continue to carry the burden of the disease. To compound the problem, in both developing and industrialized nations, increasing rates of active TB are reportedly associated with HIV infection.

Pathophysiology

The causative agent is Mycobacterium tuberculosis, a strictly aerobic nonmotile bacterium. The bacterium grows slowly, dividing only once every 24 hours, and is capable of surviving within immune cells after phagocytosis. Generally, tuberculous prostatitis results from hematogenous dissemination of the mycobacteria from the site of the primary infection. Theories of descending spread via infected urine have been abandoned, largely in light of animal studies demonstrating hematogenous spread and the scarcity of prostatic urethral TB in association with prostatic parenchymal TB.

Frequency

United States

Large autopsy studies from the first half of the 20th century report a 10-12% incidence of prostatic involvement in men with TB.

International

Direct data are lacking, although extrapolation of the US autopsy data suggests that 10-12% of men with TB might have prostatic involvement. More recent small series suggest a lower rate of clinically detected prostatic TB.

Mortality/Morbidity

• Mortality directly attributable to prostatic TB has not been reported in the recent literature. A case report described 2 patients with HIV infection who died from disseminated TB during hospitalization. Unsuspected tuberculous prostatic abscesses were noted in both patients during the postmortem examination.
• Male factor infertility, which manifests as decreased ejaculate volume, oligospermia, azoospermia, and leukocytospermia, has been observed. A perineal urinary fistula may result from tubercular cavern formation within or behind the prostate. Reports note perineal swelling, pain, and discharge preceding the development of the urinary fistula. Prostatic tuberculous abscess formation has been noted, particularly in men with AIDS.

Race

Contemporary studies have not addressed racial distributions of tuberculous prostatitis. Autopsy data published in 1949 evaluated prostatic TB in white and nonwhite patients. Of 169 nonwhite patients with TB, 18 (10.7%) had prostatic involvement during autopsy, compared with 50 of 660 (7.6%) white patients.

Sex

This condition affects only males.

Age

In 1937, Moore presented the age distribution of 243 cases of prostatic TB. Seventy-nine percent of patients were younger than 50 years. Moore describes this as "a disease of young adults."¹ The recent literature is unable to offer as large a view of the age distribution. Kostakopoulos et al (1998) presented 5 cases of unsuspected prostatic TB, all in patients aged 60-71 years.² Although this starkly contrasts with Moore's earlier data, all 5 cases were incidental findings at the time of transurethral resection of the prostate (TURP), and they do not necessarily reflect the age at which the disease first developed. Over the last 15 years, case reports of prostatic TB in immunocompetent men note patient ages of 26-85 years. Reported cases of prostatic TB in men with HIV infection document presentation in men aged 30-47 years. Most recently, Kulchavenya and Khomyakov reported on a series of 58 Siberian men with prostatic TB; their mean age was 49 years.³

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• The often-incidental finding of tuberculosis (TB) in transurethral resection of the prostate (TURP) chips suggests that many men may not have symptoms attributable to prostatic TB.
• Nonspecific symptoms, including irritative voiding, may be the only complaints. Of men with prostatic TB, 50% have dysuria and 40% have perineal pain. Renal TB, which is a common comorbidity, may manifest as flank pain. Significant differential diagnostic overlap requires maintaining a high index of suspicion for prostatic TB, particularly in men with a history of exposure to or infection with TB.
• Patients may present with male factor infertility, a well-described complication of prostatic TB.
• Sterile urethral discharge and terminal hematuria may herald tuberculous prostatitis.
• Perineal pain, swelling, and drainage can account for a less common but more overt presentation. Perineal urinary fistula has been reported.
• The most dramatic presentations may be those in men with AIDS. To date, 6 cases of tuberculous prostatic abscesses have been reported in men with HIV infection. Unlike the more insidious presentations noted in immunocompetent men, these patients presented with fever, perineal pain, and urinary hesitancy; 2 of the patients also presented with mental status changes.

Physical

• Most patients with prostatic TB in contemporary series have a prostate that may be hard, irregular, nodular, or granular.
• In patients with a prostatic tuberculous abscess, a soft fluctuant mass has been noted.
• Tenderness varies with the acuity of the process.
• Prostatic TB should be suspected in patients who have a draining perineal fistula.

Causes

• Prior infection with TB is the most important risk factor. Historically, 10-12% of men with TB had pathologic evidence of prostatic involvement during autopsy.
• HIV infection increases the risk for active TB has been suggested to increase the risk of reactivation of dormant foci.
• Prolonged steroid use and immunosuppressive therapy may increase the risk of reactivation of dormant foci.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Fungal infections of the genitourinary tract
Postsurgical granulomatous prostatitis
Post–bacille Calmette-Guérin granulomatous prostatitis

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Urinalysis: Findings that demonstrate microscopic hematuria or sterile pyuria should raise suspicion for genitourinary (GU) tuberculosis (TB) but do not definitively establish the diagnosis.
• Culture of the urine and semen with drug-sensitivity profiling
  
  
  • Acid-fast bacilli (AFB) staining of urine and semen: Standard microbiological identification of prostatic involvement of M tuberculosis relies on culture and AFB staining results of semen and 3 early-morning urine specimens. AFB staining, while rapid, has a reported sensitivity of only 52%.
  • Culture: Although it is the criterion standard for mycobacterial identification, culture may require 10 days to 8 weeks for results. Because of the emergence of drug-resistant strains, sensitivities of the mycobacteria should be determined.
• Polymerase chain reaction (PCR): Genomic amplification of M tuberculosis–specific DNA allows rapid identification of TB. The reported sensitivity and specificity of PCR are 95.6% and 98.1%, respectively. Results can be available within 48 hours.
• Semen analysis: Although it is not a required test, semen analysis may be useful in the evaluation of male infertility associated with prostatic TB. The reported semen analyses of 53 patients with genital TB revealed low volume in 89% of patients and azoospermia or oligospermia in 53% of patients. Significant leukocytospermia was identified in 77.6% of patients with prostatic TB.
• Prostate-specific antigen (PSA): PSA levels are elevated in only one third of patients. In 18 patients from a contemporary series, the median PSA level was 2.7 ng/mL (range, 0.3-31 ng/mL).

Imaging Studies

• Transrectal ultrasonography (TRUS): In persons with a soft or fluctuant prostate in whom abscess is suspected, TRUS is particularly useful. TRUS allows demonstration and localization of the collection and can then guide transrectal aspiration and drainage of any fluid for culture and microscopic examination.
• Intravenous urography (IVU): An IVU or a CT scan should be obtained to determine the presence of concurrent renal TB. Of patients with prostatic TB, 72% have pathologic evidence of renal TB during autopsy.
• CT scanning/MRI
  
  
  • Although they are not first-line studies, descriptions of CT scan and MRI findings in TB prostatitis have been published.
  • On a contrast-enhanced CT scan, prostatic tuberculosis may appear as hypodense lesions within the prostate. Additionally, focal calcifications may be identified.
  • MRI may reveal low signal-intensity lesions suggestive of abscess. These studies also may be useful in delineating the extent of any renal disease.
• Radiography: A chest radiograph should be obtained to document active or chronic pulmonary involvement.

Other Tests

• Intradermal injection of tuberculin purified protein derivative (PPD): When prostatic involvement is suspected in patients without a previous diagnosis of TB, a PPD test is a standard means of documenting exposure. False-negative results are possible, particularly during the 4-6 weeks before hypersensitivity develops and in persons who are immunosuppressed owing to various sources.

Procedures

• Cystourethrography has been used to confirm and delineate the extent of a vesicoperineal fistula associated with prostatic TB.
• Transrectal ultrasound–guided needle biopsies have been used to obtain tissue for a definitive diagnosis of the disease, to monitor response to therapy, and to ensure eradication of the prostatic disease.

Histologic Findings

Upon microscopic examination of prostatic TB samples, characteristic granulomas composed of Langhans multinucleated giant cells and epithelioid cells are noted, usually in association with central regions of caseous necrosis. Note that similar histologic changes can be seen in the prostates of patients treated with intravesical bacillus Calmette-Guérin (BCG) for transitional cell carcinoma of the bladder.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Once the diagnosis of tuberculous prostatitis is confirmed, the treatment is similar to that of other tuberculous infections. Tuberculous prostatitis must be viewed as a systemic disease, and the treatment is primarily medical. Hospitalization is usually unnecessary but may be required to treat noncompliant patients. Patients should be isolated in a negative-pressure room, if available. In addition, the local health department should be notified to aid in identifying patient contacts. Drug susceptibility testing should be performed on the isolates obtained from the prostate.

Surgical Care

Some urologists advocate resection of the prostate, although only medical therapy is usually needed. In patients with obstructive symptomatology, resecting the prostate is reasonable. In addition, in resistant tuberculosis (TB), prostate resection can theoretically lessen the infected tissue burden. Surgical treatment should be undertaken only once antituberculous therapy has been initiated to reduce the risk of exposure to the surgical team.

In persons infected with HIV, prostatic TB can present as an abscess. Surgical drainage of an abscess collection is required. Wolf (1996) and Moreno (1988) have described TRUS-guided needle drainage.^{4, 5} Trauzzi et al (1994) successfully treated one such patient with transurethral unroofing of the collection.⁶ The surgeon should obtain intraoperative samples of any abscess fluid for AFB staining, culture, and PCR, if available.

Consultations

A consultation with an infectious disease specialist is indicated.

Activity

Advise patients to use condoms during intercourse. Sexual transmission of TB via infected semen has been reported to result in a vaginal tuberculous ulcer.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

To prevent the emergence of resistant organisms, a multidrug regimen is the primary treatment. Resistance to primary antituberculous agents is increased in immigrants from Southeast Asia, China, the Indian subcontinent, and Central America. This has led to more complex empiric regimens. Compliance is difficult because of the length of therapy and the adverse effects; therefore, directly observed therapy is often recommended.

Isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and either ethambutol (EMB) or streptomycin (STP) should be the initial regimen. If the isolate is susceptible to INH and RIF, EMB or STP can be stopped and the 3-drug regimen of INH, RIF, and PZA can be continued for 8 weeks followed by 16 weeks of INH and RIF. Pyridoxine (vitamin B-6) at 25-50 mg/d should be considered in all patients to prevent neuropathy associated with INH use.

If INH resistance is documented, a 3-drug regimen of RIF, PZA, and either EMB or STP should be continued for at least 6 months. Multidrug-resistant tuberculosis (TB) has been isolated, and, if this is the case, patients should be referred to an expert in the treatment of TB disorders. In these cases, therapy usually consists of 3 drugs to which the organism is susceptible.

Initial therapy is similar to that used to treat pulmonary disease. Four drugs are used unless a drug resistance is improbable (eg, INH resistance in the community of <4%, no prior therapy for TB, no exposure to contacts with drug-resistant TB, patient is not from an area of increased resistance). Treatment is usually administered daily or, if a supervised regimen is used, twice weekly.

Successful treatment, documented with negative prostatic biopsy results upon follow-up following a triple-drug regimen of RIF, EMB, and INH for a duration of 6 months, has been reported.

In complicated cases, including recurrent genitourinary TB, prolonged therapy for a total of 9-12 months may be required.

Drug Category: Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Periodically check semen cultures to monitor treatment, and, if results are positive after 3 months, bacterial resistance to the current drug regimen or patient noncompliance should be strongly suspected.
• Histologic follow-up via repeat transrectal ultrasound–guided prostate biopsies has been recommended to ensure the efficacy of treatment.

In/Out Patient Meds

• See Medication.

Deterrence/Prevention

• Condom use is encouraged to prevent possible transmission to sexual partners.

Complications

• Infertility
• Abscess
• Perineal sinus or fistula
• Sexual transmission

Prognosis

• Most patients with prostatic tuberculosis (TB) can be cured with early treatment with a multiple-drug regimen.

Patient Education

• Condom usage
• For excellent patient education resources, visit eMedicine's Prostate Health Center and Bacterial and Viral Infections Center. Also, see eMedicine's patient education articles Tuberculosis and Prostate Infections.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Nonspecific symptoms, including irritative voiding, may be the only complaints associated with tuberculous prostatitis. Significant differential diagnostic overlap requires maintaining a high index of suspicion for prostatic tuberculosis (TB), particularly in men with a history of exposure to or infection with TB.
• To prevent the emergence of resistant organisms, a multidrug regimen is the primary treatment. Because of the length of therapy and the adverse effects, maintaining patient compliance is difficult; therefore, directly observed therapy is often recommended.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Jul 19, 2007